April 9, 2023

Presenting a Revolution in health care.

The effective use of e-clinical data for Clinical Decision Making, Education and

Research

MENZIES RESEARCH CENTRE HOBART7th MARCH 2013

Dr Terry J. Hannan MBBS;FRACP;FACHI;FACMI

WHY DO WE NEED AN E-HEALTH BASED REVOLUTION?

• The current models of health care are;– Costly and non sustainable– Continue to deliver suboptimal care– Do not provide adequate access to care– Despite technology advances better outcomes do

not always happen– For developing nations e-Health is “essential” for

managing their treatable disease epidemics e.g. HIV/AIDS

PRESENTATION CONTENTS• DEFINITIONS

• CURRENT HEALTH CARE DELIVERY AND RESEARCH• Moving from “benchtop to bedside” to ‘‘bedside to benchtop”

CURRENT ASSESSMENTS OF HEALTH CARE DELIVERY

• Current measures of care delivery• Technology beneficial and problematical• Health care funding• e-health solving BIG problems world wide • 2 short videos-making e-Health (including m-Health) work• Q&A

HEALTHCARE RESEARCH

To answer clinical questions

“benchtop to bedside” to “bedside to benchtop”

• Specific discoveries –yes, but,

• Effectiveness/practice variations/CDM/Errors• Knowledge access

Data Capture: Manual vs. electronic

.

DEFINITIONSHealth care is an information business

Information is not a necessary adjunct to care, it is care, and effective patient management

requires effective management of patients’ clinical data.

Donald M. Berwick President and CEO, Institute for Healthcare Improvement

There is no health without management, and there is no management without information.

Gonzalo Vecina Neto, head of the Brazilian National Health Regulatory Agency

April 9, 2023

WHY DO WE NEED CHANGE?HEALTH CARE IS UNAFFORDABLE!

Fineberg HV. Shattuck Lecture. A successful and sustainable health system--how to get there from here. N Engl J Med. 2012;366(11):1020-7.

April 9, 2023

Australian Health Care System(2008)[The Research base]

2005-06: ~ $87 billion 9% of GDP• 3.8% in 1960-61

• 9.0% in 2005.

• 16-20% by 2045

Australian Institute of Health and Welfare (AIHW) , Australia’s Health (2008) http://www.ahmac.gov.a

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BetterHealth

WorseHealth Less state

spendingLess statespending

Individual USStates

IS MORE $ ON HEALTH –CURRENT MODELS?

THE ANSWER-NO

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FAILURE TO COMPLY WITH GUIDELINES-COMMON

2011-Jha, A.K. and D.C. Classen, Getting moving on patient safety--harnessing electronic data for safer care. N Engl J Med.

More medical resources or spending more on Medicare is not associated with more effective care.[Costs/quality/Access}

Dr. Adeera Levin, Director, Kidney Function Clinic, St. Paul's Hospital, University of British Columbia, Rm. 6010-A, 1081 Burrard St., Vancouver BC V6Z 1Y6; fax 604 806-8120; alevin@providencehealth.bc.ca

Unsupported Clinical Decision MakingRESOURCE UTILISATION-OVERUSE

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April 9, 2023

Technology is NOT the problem. RMRS 2012

Regenstrief Institute: April 2012: 18 hospitals

• >32 million physician orders entered by CPOE • Data base of 6 million patients• 900 million on-line coded results• 20 million reports-diagnostic studies,

procedure results, operative notes and discharge summaries

• 65 million radiology images• CLINICAL DECISION SUPPORT- BLINK TIMES

April 9, 2023

SLOW LEARNERS-ON QUALITY AND PATIENT SAFETY2000-To Err Is Human Building a Safer Health System. INSTITUTE OF MEDICINE.2005 -Leape, L.L. and D.M. Berwick, Five years after To Err Is Human: what have we learned? JAMA.2011- Health Information Technology Institute Of Medicine, Health IT and Patient Safety Building Safer Systems for Better Care, The National Academies Press: Washington D.C. 2011-Jha, A.K. and D.C. Classen, Getting moving on patient safety--harnessing electronic data for safer care. N Engl J Med.

9 April 2023

Health care is a service business

• What clinicians deliver…– advice– medication– devices– surgery– physical therapy

9 April 2023

Health care is an information business

9 April 2023

Health care is an information business

• What clinicians actually do…– find information (prior records)– gather information (history, physical, lab)– record information (notes, reports, etc.)– process information (risks/benefits → decisions)– transmit information (advice, orders, letters)

• The quality, efficiency, and effectiveness of care depend on our ability to manage information

→ Electronic Health Records

“There is no healthcare without management, and there is no management without information.”

Gonzalo Vecina NetoHead, Brazilian National Health

Regulatory Agency

“There is no healthcare without management, and there is no management without information.”

Gonzalo Vecina NetoHead, Brazilian National Health

Regulatory Agency

9 April 2023

NeurologySurgery

EndoscopyHematology

EndocrinologyNephrology

Oncology

Internal Medicine

Obstetrics

Pediatrics PsychiatryCardiology

Clinical Departmental Systems-the patient(s) journey through this maze

PatientMonitoring

coronary care

intensive careperinatal care

post-surgical careperi-operative care

Radio-Therapy

Radiology

MRICT

DSARIS

PACS

Pathology

HospitalPharmacy

ECG

FunctionLabs

EEGlung function

nuclear medicine

ClinicalChemistry

Clinical Support Systems

Patient-oriented information systems that may be found in a clinical environment. J.Van Bemmel. MEDINFO.Seoul 1998

9 April 2023

NeurologySurgery

EndoscopyHematology

EndocrinologyNephrology

Oncology

Internal Medicine

Obstetrics

Pediatrics PsychiatryCardiology

Clinical Departmental Systems-the patient(s) journey through this maze

PatientMonitoring

coronary care

intensive careperinatal care

post-surgical careperi-operative care

Radio-Therapy

Radiology

MRICT

DSARIS

PACS

Pathology

HospitalPharmacy

ECG

FunctionLabs

EEGlung function

nuclear medicine

ClinicalChemistry

Clinical Support Systems

Overview of patient-oriented information systems that may befound in a clinical environment. J.Van Bemmel. MEDINFO.Seoul 1998

April 9, 2023

DATA/INFORMATION/KNOWLEDGE TSUNAMI

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9 April 2023

We are moving to a single worldwide computer (Web 3.0)

We are moving to a single worldwide computer (Web 3.0)

Apple created the platform (e.g., iPhone) but not the apps → driving innovation

Apple created the platform (e.g., iPhone) but not the apps → driving innovation

It’s all about the dataIt’s all about the dataA future of high-quality, affordable care depends on innovation

A future of high-quality, affordable care depends on innovation

April 9, 2023

Patient Centered Computing-taking control/ Data sources“The Wisdom of Crowds”

2015-every adult in the world will have a mobile phone-(WHO)

9 April 2023

Steinbrook, R. N Engl J Med 2006;354:4-7

PubMed Searches per Month, January 1997 through September 2005

HUNGER FOR KNOWLEDGE How much is “litter-ature”?[Ioannidis -2005]

>70 million/month

April 9, 2023

CURRENT HEALTH DATA MEASURMENT TOOLS

• Lack of a robust measurement program

• No nationally agreed-on methods for systematically identifying, tracking, and reporting adverse events.

• A shortage of good patient-safety metrics

• Poor quality measures are plentiful. Current patient-safety indicators, which use billing data

Poor sensitivity and specificity- their utility varies with hospitals’ billing practices.[Case-Mix, DRGs, ABF]

Ashish K. Jha, David C. Classen, M.DGetting Moving on Patient Safety — Harnessing Electronic Data for Safer Care..NEJM 365;19 NEJM.org 1756 November 10, 2011

9 April 2023

CURRENT HEALTH DATA MEASURMENT TOOLS “To improve care you have to measure it”

• Data collected in a post hoc fashion-NOT at the time of care

• Fail to engage clinicians at the time of care delivery

• Data unavailable for review until years after the care is delivered.

Getting Moving on Patient Safety — Harnessing ElectronicData for Safer Care Ashish K. Jha, M.D., M.P.H., and David C. Classen, M.D.NEJM 365;19 NEJM.org 1756 November 10, 2011

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CCDSS & RESOURCE UTILISATION

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TOTALBEDTESTDRUGOTHERLOS

Physician inpatient order writing on microcomputer workstations-effects on resource utilisation. WM Tierney and others. JAMA 1993;269:379-383

$3 million per year savings(1995)

9 April 2023

CCDSS(EHR) AND LONGITUDINAL COMPLEX CARE-1996- WE KNOW WHAT WORKS 160,000 patient over 4 years

Overall antibiotic use: decreased 22.8%Mortality rates: decreased from 3.65% to 2.65%Antibiotic-associated ADE: decreased 30%Antibiotic resistance: remained STABLEAppropriately timed preoperative a/biotics: 40% to 99.1%Antibiotic costs per treated patient: decreased $122.66 to $51.90Acquisition costs for antibiotics: fell 24.8% to 12.9% ($987,547) to ($612,500)

Our Case-Mix index which measures patient acuity levels INCREASED during this period, meaning we were treating sicker and sicker patients while better utilizing the delivery of antibiotics. (******WENNBERG 2012)

Pestotnik, S. L. Classen, D. C. Evans, R. S. Burke, J. P. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes.Ann Intern Med 1996 May 15

April 9, 2023

The Regenstrief Medical Record System. IJMI 54 (1999) 225-253

Goals of implementation.(2)1. Eliminate logistic problems of paper record-

clinical data timely, reliable, complete.

2. Reduce the work of clinical bookeeping-no more missed Dx, or forgotten preventive care.

3. Information ‘gold’ within medical records available to clinical, epidemiological, outcomes and management research.

AIDS in Africa-2000How can e-Health work here?

The Global AIDS Pandemic at a Glance-2000

• Leading infectious cause of adult death in the world• Leading cause of death in adults aged 15–59• 40 million persons now living with HIV/AIDS, 50% women• >70% of HIV-infected persons living in Africa• 14,000 new infections daily• Sexual transmission responsible for more than 85% of infections• 6 million in need of immediate treatment • Fewer than 8% receiving it

SOURCES: Quinn and Chaisson, 2004; WHO, 2003a,b.

AIDS in Kenya-2000 How can e-Health work here?

• 2.5 million persons infected (15% of adults)– Disease burden

• 4th behind South Africa, India, and Nigeria– International problem

• 1 million AIDS orphans (of 31 million citizens)– Social causes and outcomes

• Life expectancy has dropped 18 years in the past 5 years, from 65 → 47 years

– Human and economic social burdens

April 9, 2023

Face of HIV in Kenya(Africa)50% HOSPITAL BEDS POVERTY / EDUCATION

April 9, 2023

COMMUNICATION INFRASTRUCTURES ACCESS

20 years of medical records

Hierarchical decision making

Bed block/ Access

Confidentiality and communication tools

Historical “doctor knows it all”

Use of limited resources

Knowing there is a 14% prevalence of HIV/AIDS.How did we meet the health information management

needs here?

• 14-year collaboration between IU and MU1st 11 years → focus= educational exchangeKenyan request for an “EMR”

• In 2000-pre EMR>50% of the beds in Moi Hospital were filled with young people dying of AIDSno ARVs, few antibiotics for opportunistic infectionsdespair, depression, resignation

Academic collaboration-essential“Cannot do it alone!”

Clinical Information Management-the report that changed HIV/AIDS in

Africa!Use of OpenMRS (MMRS was precursor) allowed us to manage care in a timely manner

Clinical Information Management-the report that changed HIV/AIDS in

Africa!

Use of OpenMRS (MMRS was precursor) allowed us to manage care in a timely manner

Collecting this clinical information allowed effective measurement of the AIDS epidemic and therefore the ability to manage it in the future.

Clinical Information Management-the report that changed HIV/AIDS in

Africa!

Use of OpenMRS (MMRS was precursor) allowed us to manage care in a timely manner

Collecting this clinical information allowed effective measurement of the AIDS epidemic and therefore the ability to manage it in the future.

Clinical Information Management-the report that changed HIV/AIDS in

Africa!

Use of OpenMRS (MMRS precursor) allowed us to manage care in a timely manner

Collecting this clinical information allowed effective measurement of the AIDS epidemic and therefore the ability to manage it in the future.

HIV and TB = 0Not measured!

April 9, 2023

E-health and social/political change

“We have lit a candle in the darkness (of HIV/AIDS) in Africa”. Prof. William Tierney.

Government response!“This record system must be in every clinic in Kenya!” Kenyan Gov’t response.

April 9, 2023

HIV is a treatable disease, but treating millions requires

information management.

Musafa

WHY OPENMRS?• OpenMRS was created in response to

HIV/AIDS (millions). Indiana University School of Medicine had been collaborating with Moi University Faculty of Health Sciences (Eldoret, Kenya) for over a decade when their focus, by necessity, turned toward the HIV pandemic.

April 9, 2023

Outreach workers download completed forms into Mosoriot clinic's data management system daily. Automated alerts flag any alarming new symptoms/missed appointments/medication compliance. WHO/Evelyn Hockstein

An innovative home-care program using hand-held computers being piloted in the region. Monica Korir, who is living with HIV and is trained as an outreach worker

END USER INVOLVEMENT CRITICAL TO SUCCESS-CPOE

Measuring Care-the impactsEffective clinical information management using OpenMRS

The Past… The Present… The Impact…

Clinical information management

DESIGN GOALS OF OPENMRS• COLLABORATION: • SCALABILITY: • FLEXIBILITY: • RAPID FROM DESIGN: • USE OF STANDARDS: • SUPPORT HIGH QUALITY RESEARCH: • WEB-BASED AND SUPPORT INTERMITTENT

CONNECTIVITY: • LOW COST: • CLINICALLY USEFUL: feedback to providers and

caregivers is critical. If the system is NOT CLINICALLY USEFUL it will not be used.

April 9, 2023

Adult HIV/AIDS clinicsPediatric HIV/AIDS clinicsPrimary care – rural health clinicsPrimary care – urban well-child clinicsAntenatal and postnatal clinics Mother-baby register

Oncology clinicsMental health clinics Diabetes clinics Tuberculosis clinicsClinic pharmaciesClinical laboratories

Social worker assessmentsOutreach – patient follow-upDrug adherence assessments

Nutrition assessmentsFood supplement distributionMicrofinance program

AMPATH [Academic Model Providing Access to Healthcare] clinical and support programs capturing electronic data.

ALL DISEASE STATES NOT JUST HIV/AIDS

AMPATH maintenance cost only $175/patient/year in 2007 and is now less than $100/patient/year in 2009

[dividing all direct USAID/PEPFAR funding per year by the number of patients actively receiving treatment.]

CUMULATIVE CLINICAL DATAAMPATH 2001-2012

• Patients Enrolled From ~100 to ~ 14,000 /M• Cumulative patients enrolled 450,000+• Patient visits/month ~100->70,000• Cumulative patient visits > 3,500,000• Clinical obs. /month ~2.5-3 million

• Creating the Researchers “pot of gold”………>

0

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

70,000,000

80,000,000

90,000,000

100,000,000

110,000,000

120,000,000

Cumulative AMRS Observations By Month: Mar ’06 – Jan ‘12

Data capture in Kenya using the AMPATH record systemResearchers Pot of Gold

GLOBAL EXPANSION (REVOLUTION) The Millennium Development Goals Eight Goals for 2015PARTNERSHIP: Earth Institute Columbia University, UNDP,

Millennium Promise and national governments.

1 Eradicate extreme poverty and hunger2 Achieve universal primary education 3 Promote gender equality and empower women 4 Reduce child mortality 5 Improve maternal health 6 Combat HIV/AIDS, malaria and other diseases 7 Ensure environmental sustainability 8 Develop a global partnership for development

CORE PRINCIPLES FOR AN E-HEALTH SYSTEM

Data capture and management is critical to measuring health care

“We must remove ourselves from the ‘unscientific, non data driven

personal recommendations’ for care”. Dr M. Smith CHCF AMIA 2009

“The ability to feedback immediately to the people at the point of

care is critical for measuring and improving the quality of care.

[comparable and timely data from multiple sources/countries in

multiple languages] –requires a different kind of information

system to what exists now. “ A/Prof Andy Kanter April, 2011. Millennium

Villages Project

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Features of OpenMRS –RELEVANCE TO AUSTRALIA

No. 1Security:Privilege-based access:Patient repository:Multiple identifiers per patient:Data entry:Data export:Standards support:Modular architecture:

April 9, 2023 51

Features of OpenMRS –RELEVANCE TO AUSTRALIA No 2.

Patient workflows:Cohort management:Relationships:Patient merging:Localization / internationalization:Reporting tools:Person attributes:

MTCT-PlusProgram

AIDS ClinicalTrialsGroup

GN for Women’s &Children’s

HealthResearch

NHLBI Global Health

InitiativeIeDEA

April 9, 2023

SCALABILITY 2000-2012 -May 2012 WHY NOT OZ?

April 9, 2023

THE SUCCESSFUL REVOLUTION.

"Talkin' about a revolution":2009

“Now HIV/AIDS programs are not only in place but some of them, ……(partnerships)…..(AMPATH) …are openly speaking of bringing the pandemic to its knees over the next 5 years through widespread screening and effective treatment and prevention of HIV [and other diseases] .”

Braitstein, P., et al., "Talkin' about a revolution": How electronic health records can facilitate the scale-up of HIV care and treatment and catalyze primary care in resource-constrained settings. J Acquir Immune Defic Syndr, 2009. 52 Suppl 1: p. S54-7.

April 9, 2023

Two YouTube videos.

1. Data capture for MDRTB in Pakistan-direct patient care level-mHealth-data transfer.

2. Population disease monitoring –based on concepts in movie (1) using OpenMRS and mHealth-macro level data-bidirectional use.

• THANK YOU• Q&A